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r <br /> APPLICATION FOR PERMIT <br /> :I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--5420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PE <br /> gMTT EXPIRES I YEAR FROM DATE_�S��J�3 <br /> ! (Complete in Triplicate) <br /> i�. <br /> Application is hereby madE,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. `{ <br /> Job Address City Lot Size/Acreage <br /> F 6 9 <br /> �(Owner's Name Address Phone <br /> '~ onlractor 4 !O Address License 1Vo.ys?�13 Phone r 7 <br /> TYPE OF WELL/PUMP: �j, NEW WELL © WELL EPLACEMEN7 DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ S TEM REPAI ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE W L OTHER WELL PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA Aof <br /> ION SPECIFICATIONS i <br /> F1 Industrial El Open Bottom 0 Manteca xcavation Dia. of Well Casing <br /> I P Domestic/Private CI Gravel Pack ❑ Tracy g Specifications <br /> II I'1 Public CI Other l-1 Delta t Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern In ailed by <br /> Repair Work Done ❑ Type'of Pump H.P. State Work Done <br /> Well Destruction ❑ Well'DiameterSeali Dept <br /> Depth Fil r Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation _ __ P(operty,Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation t Property Line <br /> 0 <br /> SEEPAGE PITS I I Depth Size r.. Number <br /> w <br /> SUMPS L) Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C) .i! - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent'i signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subjedt to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the :following "I certitY„hat tin the rformance of the work for which this,permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 4 The applicant must c fa all required Z <br /> tions. Complete drawing on reverse lde. - <br /> fi 11�Signed Title:- T `^ Date: <br /> f p: F USE ONLY <br /> Application Accepted by Date �" A.- - <br /> 1 <br /> Pit or Grout Inspection by Date Final Inspection by Datt� -�- <br /> h <br /> Additional Comments: <br /> Applicant – Return all, copies to: San Joaquin County Public Health <br /> i� Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE 1, AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7'NO- <br /> INF (�` CASH/ <br /> I. <br /> EM 13 t �� <br /> EH 14.20 <br /> "*` <br />